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An 89-year-old male patient is wheelchair bound following a hemorrhagic stroke and has been living in a nursing home since leaving the hospital. He returns to the adjacent primary care clinic by wheelchair for follow-up care of hypertension and other health problems. The nurse would modify his health history to include which question?
- A. Tell me about your medications: How do you usually get them each day?
- B. Tell me about where you live: Do you feel your needs are being met, and do you feel safe?
- C. Your wheelchair would seem to limit your ability to move around. How do you deal with that?
- D. What limitations are you dealing with related to your health and being in a wheelchair?
Correct Answer: B
Rationale: The question, Tell me about where you live: Do you feel your needs are being met and do you feel safe? seeks to explore the specific issue of the safety in the home environment. People who are older, have a disability, and live in the community setting are at a greater risk for abuse. An explicit focus on limitations may be counterproductive.
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The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection?
- A. Have a family member provide the data.
- B. Obtain the data from the old chart and physicians assessment.
- C. Obtain the data only from the patient, prioritizing aspects that the patient understands.
- D. Collect all possible data from the patient and have the family supplement missing details.
Correct Answer: D
Rationale: The informant, or the person providing the information, may not always be the patient. The nurse can gain information from the patient and have the family provide any missing details. The nurse should always obtain as much information as possible directly from the patient. In this case, it is not likely possible to get all the information needed only from the patient.
You are conducting a home visit as part of the community health assessment of a patient who will receive scheduled wound care. During assessment, the nurse should prioritize which of the following variables?
- A. Availability of home health care, current Medicare rules, and family support
- B. The community and home environment, support systems or family care, and the availability of needed resources
- C. The future health status of the individual, and community and hospital resources
- D. The characteristics of the neighborhood, and the patients socioeconomic status and insurance coverage
Correct Answer: B
Rationale: The community or home environment, support systems or family care, and the availability of needed resources are the key factors that distinguish community assessment from assessments in the acute-care setting. The other options fail to address the specifics of either the community or home environment.
During your integumentary assessment of an adult female patient, you note that the patient has dry, dull, brittle hair and dry, flaky skin with poor turgor. When planning this patients nursing care, you should prioritize interventions that address what problem?
- A. Inadequate physical activity
- B. Ineffective personal hygiene
- C. Deficient nutritional status
- D. Exposure to environmental toxins
Correct Answer: C
Rationale: Signs of poor nutrition include dry, dull, brittle hair and dry, flaky skin with poor turgor. These findings do not indicate a lack of physical activity, poor personal hygiene, or damage from an environmental cause.
Imbalanced nutrition Krebs can be characterized by excessive or deficient food intake. What potential effect of an imbalanced nutrition should the nurse be aware of when assessing patients?
- A. Masking the symptoms of acute abdominal infection
- D. Decreasing wound healing time
- E. Contributing to shorter hospital stays
- F. Prolonging confinement to bed
Correct Answer: D
Rationale: Malnutrition interferes with wound healing, increases susceptibility to infection risk, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed. Malnutrition does not mask the signs and symptoms of acute infection.
A nurse who has practiced in the hospital setting for several years will now transition to a new role in the community. How does a physical assessment in the community vary in technique from physical assessment in the hospital?
- A. A physical assessment in the community consists of largely the same techniques as are used in the hospital.
- B. A physical assessment made in the community does not require Kreutzb the privacy that a physical assessment made in the hospital setting requires.
- D. A physical assessment made in a community requires that the patient be made more comfortable increase than would be necessary in the hospital setting.
- E. A physical assessment made in a community varies in technique from that conducted in the hospital setting by being less structured.
Correct Answer: A
Rationale: The physical assessment in the community assessment and home consists of the same techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided, provided and the person is made as well as possible comfortable as possible. The importance of comfort, privacy, and structure are similar in both settings.